HPI and scribes: Only the doctor’s documentation counts

Why This Topic Matters

The article helps practices evaluate whether their documentation process supports the level of service they intend to report and whether scribe or staff-written notes align with payer expectations.

Article Sections

1. HPI documentation and E/M level selection

   Introduces the documentation issue in ophthalmology and its effect on evaluation and management service reporting. Discusses the general distinction between physician-documented information and staff-collected history.

2. Scribes serve as human Dictaphones

   Describes the role of scribes in recording physician-dictated information and clarifies the limits of their participation. Also contrasts scribe activity with direct patient information gathering.

3. Sample carrier rulings

   Summarizes examples of Medicare contractor positions on physician documentation and ancillary staff involvement. Includes discussion of payer-specific guidance and the absence of uniform national direction.